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Physical environment checklist leads to sharp decline in inpatient suicides at VA facilities

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Tony Wickliffe, with the Media Resources group at the Central Arkansas Veterans Healthcare System, applies a mural in a room on an inpatient psychiatric unit. In accord with VA's Mental Health Environment of Care Checklist, the Little Rock facility uses such artwork to avoid conventional picture frames, which could potentially be a hazard. (Photo by Jeff Bowen)

In an effort to decrease Veteran suicides in inpatient settings, VA in 2007 launched the Mental Health Environment of Care Checklist. A multidisciplinary group of VA employees developed the program to review inpatient mental health units and eliminate hazards that could increase the chances of patient suicide or self-harm. The group focused on architectural changes, with analyses suggesting that structural hazards such as anchor points like a hook on the wall or a ceiling vent were linked to most attempted or completed suicides.

Following implementation of the program, each VA hospital with a psychiatric unit treating actively suicidal patients began using a checklist to report the potential hazards that could allow one to take his or her life. The checklist asks questions such as whether beds, walls, and ceiling vents are free of anchor points for hanging.

A study published in 2017 found that the program led to a sharp decline in suicides at VA inpatient mental health units from 2000 to 2015. Plus, there was a sustained reduction in inpatient suicides during the last seven years of that period, with none occurring in the last three years.

Principal investigator: Bradley V. Watts, M.D.; White River Junction VA Medical Center

Selected publications:

Sustained effectiveness of the Mental Health Environment of Care Checklist to decrease inpatient suicide. Watts BV, Shiner B, Young-Xu Y, Mills PD. 2017 Apr 1;68(4):405-407.

Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards. Mills PD, King LA, Watts BV, Hemphill RD. Gen Hosp Psychiatry. 2013;35(5):528-36.

An examination of the effectiveness of a mental health environment of care checklist in reducing suicide on inpatient mental health units. Watts BV, Young-Xu Y, Mills PD, DeRosier JM, Kemp J, Shiner B, Duncan WE. Arch Gen Psychiatry. 2012 Jun;69(6):588-92.


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